A do-not-resuscitate (DNR) order placed in a person’s medical record by a doctor informs the medical staff that cardiopulmonary resuscitation (CPR) should not be attempted. Because CPR is not attempted, other resuscitative measures that follow it (such as electric shocks to the heart and artificial respirations by insertion of a breathing tube) will also be avoided. This order has been useful in preventing unnecessary and unwanted invasive treatment at the end of life. The success rate of CPR near the end of life is extremely low. (See also Overview of Legal and Ethical Issues in Health Care.)
As part of care planning for seriously ill people, those people and their doctors should discuss the possibility of cardiac arrest (when the heart stops and breathing ceases) in light of their immediate medical condition, discuss CPR procedures and likely outcomes, and discuss treatment preferences. If a person is incapable of making a decision about CPR, an authorized surrogate may make the decision.
A DNR order does not mean "do not treat." Rather, it means only that CPR will not be attempted. Other treatments (for example, antibiotic therapy, transfusions, dialysis, or use of a ventilator) that may prolong life can still be provided. Depending on the person's condition, these other treatments are usually more likely to be successful than CPR. Treatment that keeps the person free of pain and comfortable (called palliative care) should always be given.
All states also provide for special DNR orders that are effective outside of hospitals, wherever the person may be in the community. These are called out-of-hospital DNR orders, Comfort Care orders, No CPR orders, or other terms. Generally, they require the signature of the doctor and patient (or patient’s surrogate), and they provide the patient with a visually distinct quick identification form, bracelet, or necklace that emergency medical services personnel can identify. These orders are especially important for terminally ill people living in the community who want only comfort care and no resuscitation if their heart or breathing stops. Living wills and health care powers of attorney are not generally effective in emergency situations. Additionally, first responders are almost always required to initiate life support unless a valid DNR order is in place and presented to them. Many states are now incorporating DNR status into a portable medical order called Provider Orders for Life Sustaining Treatment.
Portable Medical Orders
Portable medical orders communicate end-of-life care decisions of people with advanced illness. In the United States, portable medical order programs are implemented at the state level and are most commonly called Provider Orders for Life-Sustaining Treatment or POLST. Other names for such programs include Medical Orders for Life-Sustaining Treatment (MOLST), Physician Orders for Scope of Treatment (POST), Medical Orders for Scope of Treatment (MOST), Clinical Orders for Life-Sustaining Treatment (COLST), and Transportable Physician Orders for Patient Preferences (TPOPP).
These programs involve a professional-initiated discussion and shared decision-making process with people with advanced or end-stage illness. It results in a portable set of medical orders, consistent with the person’s goals of care, addressing the person’s wishes in regards to the use of CPR, the overall level of medical intervention wanted (for example, full treatment, comfort care only, or some intermediate level), and whether to seek or avoid hospitalization. Most portable medical order programs also address artificial nutrition and hydration. Some states address additional considerations, such as use of a ventilator or antibiotics that potentially could be used in a medical crisis. These programs are applicable across all care settings. In a medical crisis, emergency medical technicians and other health care professionals should first follow POLST or other similar orders. If immediate action is not essential, these orders should be reviewed with the person whenever the person's condition changes significantly, the person's venue of care changes, or the person chooses to change his or her wishes. For people lacking decision-making capacity, their authorized surrogates can act on their behalf. A portable medical order like POLST differs from advance directives in that it applies only to people with advanced illness, it provides a treatment plan in the form of medical orders for emergency decisions, and it is focused on the person’s current condition, not a future hypothetical condition.
POLST or similar programs exist in every state and a national POLST organization provides a clearinghouse at www.polst.org.
Differences Between Advance Directives and POLST
Characteristic | Advance Directives | POLST |
|---|---|---|
Eligibility | All adults, regardless of current health | A person of any age with a serious illness or frailty when the health care professional would not be surprised if the patient died within the next year or two |
Who writes it | The person, with or without an attorney | A doctor or, in some states, a nurse practitioner or physician assistant after care planning has been discussed with the person (or parent, guardian, conservator, agent, or other surrogate decision maker) |
Where completed | Any setting | Medical settings |
What it communicates | Preferences (not medical orders) regarding possible future treatment alternatives and appointment of a substitute medical decision maker (health care agent) | A doctor's medical orders for major critical care decisions that could arise because of the patient's current medical condition |
Decisions by surrogates (substitute decision makers) | Surrogates cannot make an advance directive for the patient | Surrogates can participate in and consent to POLST when patients lack the capacity to make their own decisions |
Emergency medical care | Generally does not apply to emergency care | Applies to emergency care |
Responsible for providing the documents to health care professionals wherever care is provided | Patient's and family's responsibility | Health care professional's responsibility |
Who reviews and revises the document as needed | The person who made the advance directive | The health care professional with the person or surrogate |
Use of both documents for the same person | Specifies general goals and wishes through all stages of the person's life and serves as a starting point for discussing POLST | Complements advance directives by converting the person's general goals and wishes into specific medical orders |
POLST = Provider Orders for Life-Sustaining Treatment. | ||
